| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $30 | $48 | $65 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $462 | $462 | $462 |
| Excision chalazion single CPT 67800 • Ophthalmology | $74 | $74 | $74 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $30 | $30 | $30 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $30 | $30 | $30 |
| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $46 | $46 | $46 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $14 | $80 | $145 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $25 | $25 | $25 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $75 | $75 | $75 |
| Visual field examination CPT 92083 • Ophthalmology | $60 | $60 | $60 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $24 | $24 | $25 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $23 | $36 | $48 |
| Fundus photography CPT 92250 • Ophthalmology | $20 | $28 | $36 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $26 | $26 | $26 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $28 | $41 | $53 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $9 | $9 | $9 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $1,654 | $1,671 | $1,687 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $30 | $131 | $232 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $360 | $1,080 | $1,800 |
| Total shoulder replacement CPT 23472 • Orthopedics | $990 | $990 | $990 |
| Reverse total shoulder replacement CPT 23473 • Orthopedics | $1,630 | $1,630 | $1,630 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $412 | $412 | $412 |
| Closed treatment distal radial fracture CPT 25600 • Orthopedics | $166 | $166 | $166 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $30 | $30 | $30 |
| Total hip replacement CPT 27130 • Orthopedics | $30 | $30 | $30 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $30 | $178 | $326 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $30 | $30 | $30 |
| Treatment intertrochanteric femoral fracture CPT 27244 • Orthopedics | $840 | $840 | $840 |
| Treatment intertrochanteric fracture with plate/screw CPT 27245 • Orthopedics | $899 | $1,049 | $1,198 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $30 | $410 | $789 |
| Total knee replacement CPT 27447 • Orthopedics | $30 | $485 | $940 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $30 | $299 | $568 |
| Closed treatment distal fibula fracture CPT 27786 • Orthopedics | $213 | $213 | $213 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $30 | $140 | $250 |
| Arthroscopy shoulder decompression CPT 29826 • Orthopedics | $85 | $85 | $85 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $30 | $276 | $523 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $30 | $56 | $83 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $30 | $55 | $79 |
| Arthroscopy knee with meniscus repair CPT 29882 • Orthopedics | $135 | $135 | $135 |
| Arthroscopy knee ACL repair CPT 29888 • Orthopedics | $30 | $30 | $30 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $30 | $252 | $474 |
| Laminectomy lumbar single level CPT 63047 • Orthopedics | $30 | $96 | $161 |
| Carpal tunnel release CPT 64721 • Orthopedics | $30 | $177 | $325 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $80 | $100 | $119 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $258 | $258 | $258 |
| Epidural injection lumbar or sacral without imaging CPT 62322 • Pain Management | $12 | $12 | $12 |
| Epidural injection lumbar or sacral with imaging CPT 62323 • Pain Management | $15 | $15 | $15 |
| Spinal cord stimulator electrode implantation CPT 63650 • Pain Management | $304 | $304 | $304 |
| Peripheral nerve block injection CPT 64450 • Pain Management | $31 | $31 | $31 |
| Plantar common digital nerve injection CPT 64455 • Pain Management | $25 | $37 | $48 |